2.0 Analysis 2.1 Navigation Equipment The ZIEMIA CIESZYNSKA is a new ship equipped with ultra-modern navigational instruments requiring that the bridge team assigned to the vessel has comprehensive knowledge of the use and operation of the equipment. The pilot boarded the vessel and was confronted with a radar that may have looked familiar but, due to its sophistication, would have required prior instruction in its operation to enable him to use it as the major aid to navigation in fog. Consequently, the pilot looked at the radar infrequently, preferring to pilot by visual means. Although it was found that the fog was increasing suddenly as the vessel was in the area of Bridge 11, the master was able to recognize by radar that the vessel had left her intended track. Because he was able to do this, it is evident that the condition of the radar was not a factor in the grounding. 2.2 Communication Between the Master and the Pilot Because the pilot was not familiar with the sophisticated radar, he made little use of it. Once the vessel was in fog, the radar became the main viable aid to navigation. The master assumed control of the operational set, a situation which could potentially discourage the pilot from using the radar. The master reported that he recognized almost immediately by radar that the vessel was swinging toward the bank but was unable to countermand the pilot's helm order in time to avert the grounding. On the basis of the visual clues available to him, the pilot believed that the starboard alteration was necessary. Each man was aware of a part of the whole picture; had they been communicating effectively before the perceived need to alter course, the grounding could have been averted. 2.3 Reason why the Transit was not Aborted Under the Seaway Regulations, whenever fog is forecast, navigation may be suspended. Vessels go either to anchor or they make fast at a nearby mooring facility. Because the ZIEMIA CIESZYNSKA was in a no meeting area shortly after midnight, she was committed to proceed in spite of the sudden appearance of advection fog. After the grounding and with downbound traffic stopped, the ZIEMIA CIESZYNSKA was directed to proceed to Wharf No. 10, a berth outside the Seaway channel, because of her deepening forward draught. 2.4 Situational Awareness and Information Processing Situational awareness can be defined as all the knowledge that is accessible and can be integrated into a coherent picture, when required, to assess and cope with a situation. To maintain situational awareness, a person scans for signals or cues which can be interpreted to reveal important information, such as location, speed, and the presence of hazards. A marine pilot has to maintain situational awareness to maintain safe control of the ship. When performing tasks with which they are familiar, persons know the normal flow of activities and action alternatives and, therefore, do not always consult the complete set of defining attributes before acting. There is a natural tendency to refrain from using all the cues available. Instead, a person who expects certain cues will use those cues to quickly confirm his/her assessment of the situation and take what is apparently appropriate action without referring to other information which may corroborate or conflict with the evaluation. When persons are stressed, there is a tendency for their attention to become even more narrowed so that even the cues which are present are missed, ignored or discounted. Stress can also affect the perception of time. Under stressful conditions, people overestimate the amount of time which has passed. 2.5 Reason for the Alteration of Course When the ZIEMIA CIESZYNSKA cleared Bridge 11, the ship's head was steady. According to the road bridge operator, when the vessel's stern was about 60 m from his position, it was already swinging quickly to port. Therefore, the hard-a-starboard helm order and the pilot's indication to the master that the vessel had to pass between the two white lights must have been given immediately after the stern cleared the bridge. The pilot knew the area well. He knew that no large alteration of course was required there. Rationally, he also knew that the course steered through the bridge had been correct and that no major alteration was called for in this position. The next major alteration of course should have been to port, about a mile further up the canal. In the dense fog, it is likely that the pilot, without the benefit of continuous radar information, lost his situational awareness and became visually disorientated. Furthermore, it is likely that he was also disorientated in time because he altered course long before the alteration was required. A further indication of disorientation was that the pilot was unable to recall the events which led to the grounding. The fact that the lights on the western bank of the canal had been increased to maximum intensity may have been a factor in this disorientation because the pilot mistook the lights for white lights at Mile 11. The lights at Mile 11 could not have been visible in the fog. 3.0 Conclusions 3.1 Findings The sudden worsening of advection fog obscured the Welland Canal in the area of Bridge 11. There was a minimum of communication between the pilot and the bridge personnel. The pilot did not request nor was he offered pre-departure instruction on the operation of the bridge radar. The master retained control of the radar when fog descended rapidly over the canal as the ZIEMIA CIESZYNSKA cleared Bridge 11. The pilot made infrequent use of the radar by glancing at the screen over the shoulder of the master. When 60 m south of Bridge 11, the vessel was observed to be making a large alteration of course to starboard; as a result; the vessel ran aground. The alteration is clearly visible on the course recorder trace. The pilot could not recall the events leading to the grounding, including giving the order to alter course to starboard. The master countermanded the pilot's order to alter course to starboard, discharged him from his duties and ordered hard-a-port helm but there was insufficient time for this correction to affect the outcome. The master assumed the conduct of the vessel because he perceived that the pilot was disorientated. Once refloated, because of her deepening forward draught, the vessel was directed to continue her transit and secure at Wharf No. 10. 3.2 Causes The ZIEMIA CIESZYNSKA grounded because the pilot, while disorientated, made an unexpected and erroneous alteration of course. The sudden formation of advection fog and the fact that there was no continuous exchange of information between the pilot and the master also contributed to the grounding. 4.0 Safety Action 4.1 Action Taken 4.1.1 Bridge Resource Management (BRM) Following a previous grounding occurrence involving a Canadian vessel (TSB Report No. M93L0001), the Canadian Coast Guard (CCG) drafted a Bridge Resource Management (BRM) discussion paper. It is presently being reviewed by selected marine schools and pilotage authorities. Once finalized, the paper will form the core for the development of an optional training course on BRM. In addition, the Board recently published A Safety Study of the Operational Relationship Between Ship Masters/Watchkeeping Officers and Marine Pilots which identified deficiencies in teamwork on the bridge, including communications between marine pilots, masters and watchkeeping officers. In the study, the Board recommended that: The Department of Transport require that the initial training syllabus for all ship officers be modified to include demonstration of skills in Bridge Resource Management. The Department of Transport require that all ship officers demonstrate skills in Bridge Resource Management before being issued Continued Proficiency Certificates.